Mum-to-be wasn’t told of ‘high risk’ pregnancy
Coroner to write to health minister over communication issues
AMUM-TO-BE was not told her pregnancy was ‘highrisk’ before her baby was born needing resuscitation, an inquest has heard.
Midwives found Jos Tartese-Joy’s heartbeat after mum Katherine Joy arrived at Stepping Hill Hospital on the night he was born.
But 22 minutes later, as the medical team confirmed that Ms Joy had gone into labour, they couldn’t find rhythm of the baby’s heart any more.
Little Jos was revived by medics and moved to Royal Oldham Hospital, but he could not survive without a ventilator and his life support was turned off six days after his birth.
Coroner Alison Mutch heard evidence during a two-day inquest into the baby’s death at South Manchester Coroners’ Court, in Stockport, before giving her conclusion.
The court heard that during her pregnancy, Ms Joy had low levels of PappA, a hormone which is made by the placenta.
Low levels of Papp-A can lead to complications including a lower birth weight, premature birth or miscarriage.
Ms Joy had regular scans to assess Jos’ weight and her medical notes referred to the low levels of Papp-A.
However, the court heard that she was never explicitly told her pregnancy was ‘high-risk’, and this was not understood by either her community midwife or GP.
Jos’ weight was at the 97th percentile at 32 weeks of pregnancy, but by 39 weeks it had gone down to the 75th percentile.
The court heard that at this point, Ms Joy should have been offered an obstetrics review where the seriousness of her pregnancy would have been discussed by an expert, but this did not take place.
Ms Mutch said: “I absolutely accept the evidence given by his mum that she sat and waited after the scan [at 39 weeks] for her obstetrics appointment.
“She asked if she was to have one. She was told she was not booked in for one and left. Clearly she accepted what she was told by the [hospital] trust’s staff.”
Ms Joy was seen by her community midwife six days later and offered a ‘sweep’ at 40 weeks and six days to help bring on labour.
This took place and at 41 weeks Ms Joy went into labour - but she had still not been made aware her pregnancy was ‘high-risk’ and that she should have been offered an induced labour by the 41-week point.
On December 9 last year, Ms Joy called the triage team at Stepping Hill as she believed she was going into labour.
The court heard that while on the phone, the mum-to-be was asked whether she was on a ‘high-risk pathway’, but she had not been told that she should have been.
“That’s not something that parents can be expected to disseminate,” said Ms Mutch.
Ms Joy went into Stepping Hill Hospital alone due to Covid restrictions, with Romain Tartese - Jos’ dad - initially waiting in the car park.
The court heard that she was seen by midwives at 9.10pm, but because triage were not aware Ms Joy should have been on a ‘high-risk pathway’, she was not given CTG monitoring for the baby’s heart rate - which would have lasted at least 20 minutes.
Instead, Jos’ heartbeat was measured at 118 beats per minute at 9.25pm.
At 9.47pm, when Ms Joy’s labour was established, midwives checked for Jos’ heartbeat again but could no longer find it.
Ms Mutch said: “In that period the situation changed dramatically in relation to Jos’ heart rate.
“With CTG monitoring it would have been realised immediately that the heart rate was changing.”
The court heard that further attempts were made by more senior staff to find Jos’ heartbeat, before a registrar - working beyond their shift found two flickers of heartbeat and Ms Joy was moved for emergency section.
Jos was born at 10.10pm in a ‘very poor condition’ with his heart no longer beating, before being resuscitated for 15 minutes.
His heartbeat was eventually revived, but by this time he had been deprived of oxygen, and this caused ‘catastrophic brain damage that was irreversible’.
Jos was moved to Royal Oldham Hospital where he was kept on a ventilator, but on December 15 it was agreed that this would be turned off, as he could not live independently.
A post-mortem found issues with the placenta, which itself was small and ‘not working effectively to support Jos’, Ms Mutch said.
The situation was also made worse by the restrictions placed on Mr Tartese due to the Covid pandemic, as he could not attend antenatal appointments with his partner to ask questions.
Ms Mutch added: “The benefit of having another person at antenatal appointments was lost to this family.”
The court heard that Stockport NHS Foundation Trust, which runs Stepping Hill, now has new guidance for staff on low Papp-A being a highrisk pregnancy and an ‘action plan’ was put in place following Jos’ death.
But Ms Mutch is set to write to Health Secretary Sajid Javid to raise the issues found during the inquest on the importance of clear communication ‘on a more national basis’.
She told Jos’ family: “You have lost a muchwanted child and I am just very sorry that nothing can bring him back.
“But I am sure he knew, in the very short time he was there, that he was very much loved and wanted.”
Following the conclusion of Jos’ inquest, Ms Joy said: “We would just like to extend our thanks to everybody that fought to save Jos’ life.
“They worked - often beyond their shifts in some cases - to try and help him.
“We would also like to thank the staff in Oldham that cared for Jos with immense compassion while he was alive.
“We were very grateful for the six days we got to spend with Jos.
“We also thank the coroner for doing such a thorough and amazing job of investigating.
“She has been our advocate and we are incredibly grateful for her efforts.
“It’s important that lessons are learned from our loss, which can have a positive effect on women and babies’ lives in the future.”
Ms Joy, from Marple Bridge, and Mr Tartese are continuing to raise funds for the SPOONS charity, who support families with babies on neonatal care units around Greater Manchester, in Jos’ memory.
More than £6,450 has been raised so far and further donations can be made on the family’s JustGiving page.